Surgical therapy for Crohn's disease

Abstract

Most patients with Crohn's disease will require at least one operation for that condition, either an operation to correct a complication of Crohn's disease (abscess, fistula, or bleeding) or for intractability (the failure of medical management to provide relief of disabling symptoms). Proper timing of surgery and careful preoperative preparation of the patient with special attention to control sepsis and to improving nutritional status will make the operation safer. Because of the tendency for Crohn's disease to progress despite medical or surgical therapy recurrences after operation are common and the surgical procedure should be limited to correcting the complication at hand. For Crohn's disease of the small bowel or of the terminal ileum and right colon, a conservative intestinal resection and anastomosis is usually the procedure of choice; nonresective procedures such as bypass and strictureplasty are useful in special situations. More than half of the patients so treated will eventually develop recurrence that may require one or more subsequent operations. The adverse effects of resection will be minimized by conservative surgery and by careful long-term management of the altered intestinal physiology. Some patients with Crohn's colitis have limited colonic disease where continence can be preserved by resection and anastomosis, although the recurrence rate is high. Total proctocolectomy for Crohn's colitis provides much better assurance of long-term freedom from recurrence but at the cost to the patient of a permanent ileostomy. Surgery for Crohn's disease is not curative but offers effective palliation for the complications of this progressive and poorly understood condition.